Educational Retreat Follow-Up Report

Andrew Phelps

February 28, 2002

1. What did you experience/learn/absorb from the Retreat?

The Educational Retreat (ER) was structured as a reconstitution of the historical dialogue arrangement between the mental health provider system in Santa Clara County and the mental health client activists. Senior managers and stakeholders ('participants') and local and out-of-county clients ('facilitators') were invited in equal numbers to spend the day in this program of dialogue reconstitution.

A. The ER began with greetings from Mental Health Director Nancy Pena and from Barry Fultonberg, co-founder of the historical Santa Clara County client activist group United Consumers Movement (UCM). Both parties spoke for the belief that after more than ten years of empowerment struggles the grounds existed for shaking out the sediment of old attitudes historically learned and thereupon to arrange the conversation with a greater wisdom and clarity. The focus posed was on the moral psychology of the dialogue, or how now to frame and represent the ways the two parties each do and should take responsibility. It was considered that with the large number of clients served by the extended County system, in excess of 30 thousand, the small number of client activists who had dedicated themselves to client advocacy had a role to play in reflecting the world view of the clients.

B. Nancy Pena suggested what was called a union recognition paradigm as a unifying perspective for the coming together of the moral centers of the providers and the clients. This called for a mutual acceptance of the principle of independent client organizing and the notion that negotiation would replace confrontation as the principal manner of structuring dialogue. I wrote, "The independent client organizing, the 'union', can win the right to, and then pursue negotiation over the boundaries of decent and humane treatment, [over the boundaries] of fulfillment of our visionary potential as human beings." Two meetings were organized at the home of former UCM activist Annette Maguire, with the purpose of developing a mutual acknowledgement of this paradigm.

C. The construction of the Plan of the Day for the ER centered on the problematic of bridging the two cultures, of identifying the modality for the diplomacy between that of the clients and that of the mental health providers. To build a client-driven system requires first of all a recognition and delineation of the prodigal role of discrimination and its integral relation to the approaches providers take to the treatment system. This was extended into the framing of a discussion regarding 'trauma of treatment', the recognition, that is, of the essential existential experience of the clients in facing the discriminatory character of the treatment system. And finally the 'accountability' insight of the clients movement was introduced, as the framework by which the values of the client culture are sustained.

D. The actual dialogue for the Los Gatos retreat August 17th was built around module texts which described the elements of the bridging plan, and the notion of 2×2 groups for intimate personal interchanges. By bringing in out-of-county clients through the organizational work of the Accountability Caucus the possibility of restarting the dialogue structure in a new place was supported. By the creation of the Santa Clara County Clients Network (SCCCN) on July 27th, the possibility of transformation of the UCM heritage into a 'union recognition' program was sustained. Approximately 23 senior managers and stakeholders participated in the ER and shared a rich and surprising experience of authentic person-to-person discussion.

2. How do you think we should follow up on implementing the dialogue agenda?

The follow-up document circulated at the Retreat had four topic areas labeled "transformation projects." These were:

i. [Line Staff] Develop a work group dedicated to supporting clients with Vision.

ii. [Community Support] Construct a true community coalition by targeted outreach.

iii. [Institutional Services] Redesign programs as true alternatives to work at a higher level of trust.

iv. [Clients Network] Build the 'circle of responsibility' by the method of Accountability Training.

These have not yet been followed up on, but this constitutes the only available text representing prima facie agreement as to the practical implications of adopting the 'dialogue agenda'. They are meant to provide a framework for working through the impact of trauma of treatment on the dialogue process.

Nancy Pena expected that the construction of the follow-up process be developed in consultation with the staff and stakeholders as appropriate. What is to be noted is that there are two opposing threads in the matter of change. There is a 'minimal logic' which is in sync with the flow of change at the state level, and there is a 'maximal logic' which targets the level of serious change. In my interviews with senior managers, I have selected out the perspectives which I thought evinced a heartfelt connection with the target of serious change.

A. We need to integrate the 'dialogue agenda' with the perspective of the systems of care (SOC). Nancy Pena submitted that the first line of follow-up work would be with the adult and children's SOC groups. This makes sense because the central contribution of the Mental Health Division is in the provision of outpatient services by the SOC line staff. I have been given to understand that the children's SOC is more advanced in its programmatic involvement with its constituency, notable with the parents' groups.

The dialogue problem is intense at the SOC level because it is immediate and direct and any misunderstandings hit hard. Phil Cushman wrote a paper, Will managed care change our way of being? where he shows how line staff can and must work together to stand up to the treatment-unfriendly aspects of managed care. In general I noted that the implication was that serious and technically demanding work is required for a 'new tradition' in client-provider relations to evolve. As Jaime Lopez suggested to me, the meaningfulness of programmatic involvement with the constituency is reflected in the civility of the interactions: The feeling is deep and woundedness tends to be near the surface.

B. We need to develop our dialogical interface in the broader community. This involves the mandated community oversight Mental Health Board, the 'Community Coalition' as Allan Rawland has constructed it, the families' movement NAMI, and .. the body politic. The 'minimal logic' in California today speaks to the partnership of providers, families and clients, MHB/C's and DMH in a kind of mental health coalition. But beyond that there is a wide variety of community institutions, educational institutions, and so forth where people learn of the nature of the mental health system and its paradigm, which could be reached.

What we must do is pay respect to the subjectivity of the clients. Maria Fuentes pointed out to me that at every level the tendencies towards objectification need to be challenged and worked on. We need to bring the 'dialogue agenda' to the society by the example we set. We need to identify and define the ways we can inform the community of the human face of the mental health work: "Nothing about me, without me."

C. In Santa Clara County as in many other areas the County inpatient system is vested in Acute Psychiatry which is a separate division of SCVH&HS. For whatever reason, in organizing the ER we found it hard to involve Acute Psychiatry at the depth we'd have cared to achieve. In interviewing the senior managers, I heard over and over again the communication of their frustration with this dividing line of the system. Yet any transformation of the system which neglects the role of the institutional system is doomed to have limited impact.

We need to redesign programs as true alternatives to work at a higher level of trust. The O.C.E. today is developing a program of inpatient support groups; in general where the suffering is most acute, we must connect better so as to minimize catastrophic impacts. In the words of Pablo Garcia-Gañan, "The Mental Health Division should regain its soul." This must be considered the most challenging problem to the successful implementation of the 'dialogue agenda'.

D. For the clients, choice rather than forced treatment is essential - but this must be balanced by the way people take responsibility. In California as elsewhere, the 'minimal logic' of empowerment calls for self-help and peer counseling opportunities. The question which arises is the extent to which the clients take responsibility, the extent to which they act ethically, act from the paradigm of respect. The ER follow-up envisions the involvement of the Santa Clara County Clients Network (SCCCN) in the 'union recognition' process, in the construction of the respect paradigm for the clients.

If we are to build the 'circle of responsibility', we need to support the development of the independent clients movement. For this to realize its potential, for the impact of debilitating factionalism to be held in check, the development of a system of respect education is necessary. From the perspective of Chris Zubiate, the opportunity for people to develop their Visions is paradigmatic. The 'maximal logic' of the follow-up plan is to realize the educational mandate of client empowerment, such as the plan envisioned as the Accountability Academy.

3. What are you doing to follow up on the lessons of the Retreat?

The first part of the Retreat follow-up document described two points of departure. The first was "design of follow-up work group" and spoke to the client network (now: SCCCN) and selection of others; the second was a list of "target groups" for follow-up work. In actuality, the process bogged down at a level preliminary to this. This report is presented as an analysis of the preliminary problems we have discovered, which have prevented people from reaching those points of departure.

A. Phil Cushman says in Constructing the self, constructing America (p. 356), "If we can open our eyes, or rather lift them and see more of what is possible, we will be able to move toward a critical, subversive, and perhaps even occasionally 'constructive' moral discourse." It seems that the ER actually constituted a space where one of these "occasionally 'constructive' moral discourses" took place. However, the subtext of this comment is the 'usually' that corresponds to the 'occasionally'. In order to continue directly and on point, we would have needed to put into the process the level of focus and care appropriate to such a bold endeavor: We did not.

What actually happened, as I see it, is that the level of 'suffering' involved in this work (according to the thinking of Pablo Garcia-Gañan) was not honored in the planning. As (projective) consultant to the follow-up process, I did not have a clear understanding of the job and career implications for me, nor did I agree to the logic of any. Despite the general recognition of the merit of the ER, the integrity of the clients 'dialogue model' was challenged by hasty and overdrawn comparison to the dominant model of client activism in California. And this all took place right in the middle of the national crisis now known as 9-1-1 and in the middle of a round of budget cuts triggered by California's energy crisis and the dot-com meltdown.

B. The first meeting of the ER Follow-Up Committee met under ill-starred conditions September 25, 2001. We weren't ready to look at the reconstruction the moral interface of service delivery in a transformation frame; Nancy Pena felt that a streamlined work group [with members of the Office of Client Empowerment, Dr. Stephen Blum, and myself and herself] should talk out a common perspective and initiate the follow-up activity. I did not understand this intention clearly, but was focused rather on the problematic of searching out what would possibly separate the 'occasionally' out of the 'usually' as per Cushman's formulation. The clients were also distracted by preparations for the forthcoming California Network Forum (Nov. 9^th), where the SCCCN was to present the ER experience to the California clients.

Even though the result of the meeting was subjectively distressful, I feel that the primary characteristic was an awkwardness that stems from addressing the implementation aspect prematurely, which metaphorically I likened to a 'bungee cord' experience. There were accusations of 'monologism' and 'bullying' leveled at me, and there was my failure to back off the pace of the proceedings and prepare the discussion in a more accessible manner. While I think these accusations were overdrawn, still it was my responsibility to lead people through the complexity of this circumstance, and I did not do so. Instead we entered into Cushman's 'proper adventure' with our eyes and minds closed "to the remarkably intertwined nature of the cultural, moral, political, and psychological in human being." (ibid.)

C. When the dialogue between the UCM and the mental health system began more than a decade ago, it was not characterized by 'sweetness and light', but rather by a serious and abiding cross-communication with the stresses attendant on that misunderstanding. Nor was it easy for folks to cope with, and neither was the misunderstanding generated by the path we took September 25th easy for us to cope with. The second meeting of the ER Follow-Up Committee took place on October 16th and it exposed the unaware side of the social change process, which metaphorically I likened to a 'hornets nest'. In that type of situation "our eyes are closed to all that [remarkably intertwined nature, and] psychotherapy is nothing more than an effective tool of the status quo." (ibid.)

The following comment should be taken in the spirit of thoughtfulness rather than the spirit of accusation. The exposure of 'unaware contents' is known in psychology to be informative as to the nature of the place where insight is lacking: The contention is in arriving at a meeting of minds about how the 'unaware' materials are to be transformed into the domain of reason. For the work group, the subjective characteristic of the discussion appears to have been the matter of finding a way of engaging my 'attitude' in a kind and considerate manner; for me, it hearkened back to the issues that are raised in my letter of reasonable accommodation under ADA. In my estimate what should be informative about this experience is that principled argument, the achievement of moral inclusion through dialectic, through the give-and-take of reason, needs to be better supported by the process.

D. When we did the ER we opened up a path towards the 'dialogue agenda' in mental health service delivery. What is hard or sometimes unfamiliar for us to gauge in full is the richness of the making of history and the style of being appropriate for the extraordinary nature of the attendant disclosure space. We didn't see what we needed to do then in the time frame where we needed to do it. The third meeting of the ER Follow-Up Committee on November 16th was introduced by Nancy Pena by saying that the previous meeting was "not an easy meeting": She likened the situation in front of us to a "rocky road."

When Mission Valley House, the clubhouse model self-help project of a decade ago, was established, the clients say it soon had a profound positive effect on many people. But circumstances did not permit this model to continue in the same format .. in my view, this breakdown frames the historical experience of change in the Santa Clara County mental health system and the problems attendant thereunto. After making a fitful effort to sustain a dialectical interpretation of the proceedings, and failing to achieve ready connection and communication, I concluded that we were not working the 'disclosure space' properly, and that it was my responsibility to quit. I did not imagine that things couldn't be developed as we had all hoped, only that the way we were going about things did not rise to the level of the work problem we were facing.

4. What should be happening at Mental Health in order for the clients to be excited at being involved?

For the ER, it was posed that the organizational forms are reflected in moral practices and therefore that we should consider what organizational form would reflect the desired moral practice, here characterized as "clients are excited about the treatment experience." There is a general agreement among the managers, stakeholders, and client activists that this is a worthwhile way to go, but there are serious differences about the approach needed and the pace to be expected. Ultimately, how this is to be done depends on a kind of social change insight which would command the understanding and buy-in of the line staff and the recognition of the complexity of the client culture that would come from a deeper familiarity with its social fabric. Such insight is linked to (1) formulating mental health as an educational as well as a treatment process, that validates the life purposes of the clients, and (2) the problematic of extending awareness of the way we actively construct social relations.

If and when this ER follow-up process is to be continued, the following complexities should be actively considered.

A. It is necessary that the line staff become involved in moral dialogue with the clients at a heart level. In the language of psychology, this corresponds to the problematic of interpretation: hermeneutics. We will have to consult with the line staff in the multiple and complex way necessary and find out how they see that this might be achieved. And we will have to work out among ourselves the way we can represent this concern, the support frameworks for its implementation, the handle on risks and liabilities attendant upon the line staff, and the manner of an orderly and respectful process for working through such a transformation.

From the client activist perspective, it is important that the clients articulate the "nothing about me without me" value system and build it deeper into their culture. The clients are involved in the treatment/education process of mental health and they need to frame for themselves the consequent responsibilities. This can be described as the logic of 'client psychology' and the task which stands before us. As an example of such work, see the recent document, It's time for a new paradigm, by Sylvia Caras.

B. It is necessary that an affirmative format be found to acknowledge and transform the historical legacy of the 'client underground'. If the clients are to implement the 'dialogue agenda' successfully, they face the huge task of coming up from their underground social condition. The moral content of their interactions is a non-fact of modern society - it presents as shrill monologisms and Mikhail Bakhtin's analysis of the 'loophole' of underground rhetoric is not taken into account. Until such time as we come to grips with the client dialogue issue, the ethical issues related to client employment in the mental health system are going to be murky at best.

Traditionally - before the acknowledgement of the empowerment issue - the mental health provider system typically treated clients as beings without moral standing in society. Now with the ER having come so far as to consolidate the dialogical opening that stems from the implementation of empowerment, we are face to face squarely with the more advanced question of grasping how to evaluate the moral standing of different client actions. The traditional argument that differences among the clients originate in 'personality issues' begs the question of there being legitimate issues of substance subject to rational examination. "Coming up from the underground" in large part means for the clients the construction the grounds for mainstreaming the internal discourse of the client culture.

C. It is desirable to construct the employment roles of the client activists so that they are educational in substance rather than narrowly competitive with the professional staff. It is a homily that mental health professionals worry that hiring clients as providers threatens to render themselves redundant. In my view this confuses the role of dedication and technical understanding of mental health with the creative opening afforded by clients bringing back their direct experience with madness into the working of the system. The primary moral content of the client experience needs to be rendered in an educational framework where knowledge is imparted on a peer basis as instruction in the involvement in mental and emotional life.

The present trajectory in client employment not only begs the question of ethics, it also privileges a logic of bureaucratic work style. At the ER major attention was given to the question of treatment merging with discrimination, and vesting the client providers with the provider capacity gives them a 'double bind' kind of issue in regards to the implications of discrimination. If we are to render mental health service provision with the respect and dignifying aspect required, if we are to work past the 'warehousing' dynamic that characterizes mental health service delivery today, we will have to privilege new 'educational' roles for the client work force. The emphasis on didactics rather than management/treatment will clear the air for client involvement, for the rendering of mental health as a service to the whole of the mental being of the recipients of service.

D. It is necessary that the 'soul' of good social relations - the relational dance - be constructed through a kind of appreciative inquiry approach. When the caring necessary for a wholesome helping relation breaks down, the spirit that nurtures participatory excitement breaks down with it. The human condition of 'suffering' must needs be worked on positively, and the outreach to do so can be characterized as 'appreciative inquiry'. Excitement at the prospect of and in the experience of involvement with the mental health system can only be built up if we upgrade our capacities to appreciate what people's experience of madness truly means to them.

The client activists must face the implications of the 'relational dance' and themselves sustain this experience of 'soul'. The clients - upon whom the woundedness of the madness experience falls - must in the final analysis educate the society as to the respect required for engaging the issue of madness. I believe that only in coming together around the discourse of social constructionism can we effectively unite the providers and the clients. With appreciate inquiry and allied tools we must make the community and the society at large finally appreciate the human dilemma (crisis/opportunity) of madness.

5.How do we help bring the client subculture up from the underground?

This I believe to be the key question. In my opinion, this question is beyond the scope of this report. The Accountability Caucus is part of the process for achieving this goal. A true plan for continuing self-help development will need to derive its impetus from the imperative here implied.